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HomeMy WebLinkAboutBLDP-19-002512 a2 PA MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a=_-a,_s South Yarmouth � ?;;rl_>• CtTY(rOWN MA DATE 10/23/2018 PERMIT#/✓�,P�R- / JOBSITE ADDRESS 109 River Street OWNERS NAME McCarthy P ' OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ID PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO D FIXTURES L FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 41 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01L/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN / t FOOD DISPOSER f/ FLOOR/AREA DRAIN J INTERCEPTOR(INTERIOR) t KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET • URINAL WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES 1 WATER PIPING - OTHER INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES [/NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY la OTHER TYPE INDEMNITY ❑ BOND Q OWNER'S INSURANCE WAIVER lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT.❑ SIGNATURE OF OWNER OR AGENT I hereby gertify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge end that all plumbing work and installations performed under the permit issued for this appicatton will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# PL15162 GNATU MP R( MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC I21# 3944 • f • COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd I CITY Harwich-Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andyahphcllc.com -.7